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The Gateway Paper – towards a health systems reform


Published in The News International on March 19, 2006:

Released on January 9, 2006, the first publication of Pakistan’s Health Policy Forum (PHPF), the Gateway Paper entitled “Health Systems in Pakistan – a Way Forward” is set within a broad context. A context relevant to health on the one hand and one that cross cuts with broader social sector issues, inter-sectoral processes and mainstream governance and sustainable development challenges, on the other.

Pakistan’s Health Policy Forum has recently been created as the country’s first health sector Think Tank with the overarching mission of providing an independent voice for the promotion of the health and well-being of the country’s population. Its specific objectives are to review and analyze health ‘policies’ and ‘systems’, assess gaps and offer solutions to address impediments and to catalyze change through technical and policy support. The Forum/Think Tank is envisaged to play an important role in promoting accountability of decisions by educating the civil society in the dynamics of health care delivery, policy and financing; mobilizing their participation in the health policy process and mainstreaming the voice of the civil society in decision making – an attribute critical to strengthening the ‘societal’ political culture. An initiative of the NGO Heartfile, Pakistan’s Health Policy Forum is the largest grouping of stakeholder organizations and individuals in the health sector. (http://heartfile.org/hpf.htm).

In a true sense, the Gateway Paper is a gateway or opening of new effort to address the pressing health needs of the country. The intent is to articulate the raison d’être for health reforms within the country, propose a direction for reforms and emphasize the need for an evidence-based approach to reforms. The Paper has also been structured to assist PHPF with the setting of its priorities and to guide its analytical and technically supportive functions needed to support health systems reforms in the country.

Making a strong case for ‘systems reforms’, the Paper provides linkages with Pakistan’s health systems and its policy cycle providing a strategic view on how they can work better together. The Paper reviews issues and proposes solutions for the basic functions of health systems – stewardship, financing, service provision and inputs. It also discusses three distinct interface areas critical to performing these functions; these are the federal-provincial interface, decentralization and the public-private interface. In addition, the Gateway Paper also focuses on several overarching health paradigms such as health promotion, legislation, research and the inter-sectoral scope of health as singular areas, with the understanding that each of these is cross-cutting in its scope. In its Finale, the Gateway Paper synthesizes recommendations from each health systems domain discussed in the paper and presents a viewpoint on the proposed directions for evidence-based health systems reforms in Pakistan. The proposed reforms point in the direction of four broad areas namely, reforms within the health sector, overarching reforms, reconfiguration of health within an inter-sectoral scope and generating evidence for reforms.

Within the health sector, the proposed reforms focus on strengthening the role of the State as the principal steward of the health system; setting of priorities for the use of public funds and definition of priority services to be provided universally and developing alternative service delivery and financing options at the basic healthcare and hospital levels. Within the context of the latter, this includes community co-management and contracting out arrangements for basic health care, maximizing efficiency in the same system or transferring management to lower levels of government – an option complementary to the administrative arrangements within decentralization – whereas with reference to hospitals this involves granting autonomy at a management level and the introduction of cost-sharing at the level of financing. The paper also makes a strong case for building the capacity of and effectively deploying human resource, establishing a conducive and rewarding working environment and initiating measures to redress imbalances with regard to the existing staff.

At an overarching level, three proposed directions of reform have been articulated; the first involves establishing a legal, policy and operational framework for public-private partnerships in order to foster arrangements that bring together organizations with the mandate to offer public good on the one hand, and those that could facilitate this goal through the provision of resources, technical expertise or outreach, on the other. The second includes building conscious safeguards in order to offset the risk of creating access and affordability issues for the poor in the new service delivery arrangements which mainstream the role of the private sector. This includes the establishment of social health insurance as part of a comprehensive social protection strategy that scopes beyond the formally employed sector, providing a widely inclusive safety net for the poor and the strengthening of waiver and exemption systems in order to provide subsidies to treat poor patients. And the third focuses on institutionalizing civil service reforms centered on good governance, accountability, crackdown on corruption, factoring in of performance-based incentives, mainstreaming managerial audit and building safeguards against political and external interference.

The proposed reforms within an inter-sectoral scope entail developing alternative policy approaches to health within its inter-sectoral scope with careful attention to the social determinants of health and several contemporary considerations that influence health status – in other words, broadening the ‘healthcare system’ to a ‘health system’. Most of the available information about Pakistan health systems refers to provision of and investment in health services curative more than preventive and palliative – directed at individuals and populations. This constitutes the healthcare system; however a health system is much broader; this underscores the need for health to be viewed in its inter-sectoral scope. It is well established that many factors which determine health status range much broader than those which are within the realm of the health sector. Health cannot be extricated from the political, economic, social and human development contexts. It is well established that liberalization of international trade, global infectious disease pandemics, natural disasters and humanitarian crises can be detrimental to health outcomes as can be changes in international cooperation and geopolitical situations which can have implications for the manner in which health is resourced in a country such as Pakistan.  The proposed reforms in ‘health’s intersectoral scope’ necessitate redefining targets within the health sector in order to garner support from across various sectors and setting these targets within an explicit policy framework in order to foster inter-sectoral action. In addition this also warrants the creation of intersectoral agencies that concentrate on prevention and health promotion at multiple levels – legislative, ministerial and others as necessary; development of dedicated provincial agencies that implement such programmes and overarching policy and legislation for health promotion.

The fourth area of emphasis is on generating evidence for reforms. Health reforms must be firmly grounded in evidence, which in turn, should be utilized for appropriate modifications as the reforms get on their way to being implemented – an approach, which allows action accompanied by rigorous evaluation and up-gradation of programmes and policies. The individual components of the health reforms being proposed also mandate robust evaluation; this can allow the evaluation of competing concepts and can, therefore, guide the up-scaling of appropriate initiatives for broader systems-wide adoption. This is critical to the development of well-structured and sustainable service delivery and financing mechanisms. The Gateway Paper outlines a list of priority areas where health policy, systems and operational research should focus in order to yield evidence critical to the success of the proposed reforms. The Paper also outlines policy frameworks, institutional mechanisms and norms and standards required to support the reforms it proposes thereby providing a clear linkage of conceptual thinking to practice.

The proposed reforms outline the need to strengthen systems and institutions, build capacity and foster a greater commitment to basing decisions and actions on evidence. However, health cannot be extricated from the political, economic, social and human development contexts and reforms within the healthcare system and the health system at large cannot be separated from several overarching processes. Poor regulation, gaps at the governance and management levels and lack of appropriate incentives contribute to lack of efficiency, staff absenteeism and abuse; these are compounded by lack of accountability within the system and lapses in social justice, which in turn cannot be extricated from overall macroeconomic and social development. Sustainable progress at the health systems and healthcare systems levels, therefore, depends to a large extent, on the manner in which progress is made in all these areas in addition to human development, the overall rate of economic growth and improvements at a governance level. With the current trend of economic growth, it is important to pay close attention to these overarching processes as these are critical to impacting social sector indicators within the country. Health reforms can undoubtedly be an entry point for these structural changes

The author is the founder and president of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum and the author of the Gateway Paper. E mail: sania@heartfile.org

March 19th, 2006
Sania Nishtar,
Health Systems,Governance,
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